Insurance D&O Signature Pack

INSURANCE D&O SIGNATURE PACK

Applicant / Insured Information

Applicant Name:

Corporation Limited Liability Company Nonprofit Partnership Individual

Primary Contact / Title:

Date of Birth (Primary Contact, if individual):

Telephone:    Email:

Policy Details

Coverage Limit: $    Retention / Deductible: $

Annual Premium: $

Policy Period From: to

Coverage Selections

Please indicate coverages requested:

Side A — Non‑Indemnifiable Losses to Directors and Officers

Side B — Company Indemnification Reimbursement

Side C — Company Entity Liability

Employment Practices Liability (EPL) — optional endorsement

Exclusions & Acknowledgements

The following exclusions are standard to this policy form unless otherwise negotiated. Applicant acknowledges receipt and understanding of these exclusions and warrants that no person for whom coverage is requested has knowledge of facts or circumstances likely to give rise to a claim except as disclosed in this pack.

• Fraudulent, dishonest or criminal acts by an insured where such acts are finally adjudicated.
• Claims arising from bodily injury, property damage or pollution.
• Prior acts or known circumstances not disclosed in the Prior Claims section below.
• Contractual liability assumed by the insured except to the extent the insured would have been liable in absence of the contract.

Initial to acknowledge understanding of exclusions:

Initials:

Beneficiary / Payee Designation

Primary Beneficiary Name:

Relationship to Insured:    Percentage:

Relationship:    Percentage:

Claims / Prior Acts Disclosure

Has any person or entity proposed for this insurance been involved in any claim, suit, regulatory inquiry, or investigation during the past five (5) years?    Yes    No

Authorization, Certification & Declarations

The undersigned hereby declares that the statements and particulars in this Insurance D&O Signature Pack are true, complete and accurate to the best of the undersigned's knowledge and belief. The undersigned understands and agrees that this Signature Pack, together with any attachments, schedules and materials provided herewith, will form the basis of the policy and may be relied upon by the insurer in determining insurability and premium.

The undersigned further represents that no material information has been withheld, and covenants to give immediate written notice to the insurer of any material change in the facts set forth herein between the date of signing and the inception date of the policy. Misrepresentation, omission or concealment of material facts may render coverage void or permit the insurer to rescind coverage to the extent permitted by law.

The undersigned authorizes the release and exchange of information pertinent to underwriting or claims between the insurer and any person or entity having knowledge of such matters for the purpose of evaluation of this application and any subsequent claims, subject to applicable confidentiality laws.

By checking the box below, the undersigned certifies under penalty of perjury that the information provided in this Signature Pack is true and complete and that the person signing below is authorized to sign on behalf of the named insured.    I certify the foregoing

Payment & Premium Authorization

The applicant authorizes the insurer to charge the premium as indicated above and acknowledges that coverage will be effective only upon acceptance and payment in accordance with the insurer's procedures. Payment terms, installments and cancellation terms are governed by the policy.

Check Electronic Funds Transfer / ACH Credit Card

Document Attachments & Checklist

Please indicate documents included with this Signature Pack:

Completed Insurance Application
Most recent financial statements
Corporate minutes or resolution authorizing purchase
Prior policy declarations (if applicable)

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